2026 Proffered Presentations
S136: THE MANDIBULAR STRUT AND INFERIOR PETROUS CAROTID TRIANGLE AS KEY LANDMARKS FOR ENDOSCOPIC ENDONASAL LOCALIZATION OF THE PARAPHARYNGEAL INTERNAL CAROTID ARTERY
Maria Karampouga, MD1,2; Liang Xia1,3; Gregory J Varga4; Eric W Wang1; Carl H Snyderman1; Paul A Gardner4; Garret Choby1; Georgios A Zenonos4; 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; 2Department of Neurological Surgery, Nicosia General Hospital, Nicosia, Cyprus; 3Department of Neurosurgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang 41,2001,31,3, China; 4Department of Neurological Surgery, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Objective: To define anatomical landmarks for the parapharyngeal segment of the internal carotid artery (ICA) relevant to the endoscopic endonasal approach (EEA).
Methods: Four cadaveric heads (8 carotids) were dissected endonasally employing “the transpterygoid-transmandibular strut-transmedial jugular tubercle-inferior transpetrosal EEA”. Extensive endoscopic laboratory investigation of the ICA course led to the development of a technique, which was subsequently demonstrated in a nasopharyngectomy and presented as a step-by-step guide (Figure 1).
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Results: Using a transpterygoid approach, the foramen lacerum was reached, the parasellar and paraclival ICA segments were exposed, and the lingual process was removed. Drilling proceeded through the mandibular strut and adjacent petrous base along the inferolateral surface of the horizontal petrous ICA (hpICA) up to the vertical petrous ICA (vpICA). The medial jugular tubercle was drilled, and the eustachian tube disconnected and excised. Dissection was performed from superior to inferior using the vpICA to locate the carotid foramen and parapharyngeal ICA (ppICA). The “inferior petrous carotid (IPC) triangle” was identified and delineated by the ventral hpICA, vpICA and the line connecting the carotid foramen to the lacerum cartilage. Its importance lies in providing access for an anteroinferior petrosectomy, which is obstructed by the hpICA in an open approach, while its inferior apex marks the depth of the ppICA, enabling safer parapharyngeal space dissection.
Conclusions: The mandibular strut and IPC triangle serve as valuable landmarks for tracing the petrous ICA, facilitating reliable craniocaudal localization of the ppICA during EEA.